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To cite: Arbizo JC,
Dalal K, Lao V, et al. Safe
preoperative regional nerve
blocks. BMJ Open Quality
2022;11:e001370. doi:10.1136/
bmjoq-2021-001370
► Additional supplemental
material is published online only.
To view, please visit the journal
online (http://​dx.d​ oi.​org/​10.​
1136/b​ mjoq-​2021-0​ 01370).
Received 25 January 2021
Accepted 14 December 2021
© Author(s) (or their
employer(s)) 2022. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
and permissions. Published by
BMJ.
Anesthesiology, UTHSCSA, San
Antonio, Texas, USA
Correspondence to
Dr Joseph Christopher Arbizo;
​arbizo@​uthscsa.e​ du
Safe preoperative regional nerve blocks
Joseph Christopher Arbizo  ‍ ‍, Kajal Dalal, Veronia Lao, Frank Rosinia,
Temiloluwa Adejuyigbe
ABSTRACT
Background  Procedural time-­outs and checklists are
proven to be an effective means of improving teamwork
and preventing wrong-­sided procedures. The main
objective of this study was to ensure that all regional
nerve blocks being performed in the preoperative area at
our hospital were executed with a proper time-­out. The
goal of this project was to increase integration of a safe
preoperative block process including a time-­out checklist
to ensure; complete consents, correct patient and laterality
were marked prior to each procedure. We focused on
recognising events that took place before, during and
after the nerve block including non-­compliance with the
checklist and deviations from protocol.
Methods  A safe preoperative block process current and
future state flowchart, revised time-­out checklist and
action/implementation plan as part of our Plan–Do–Study–
Act model was constructed using a multidisciplinary
approach. Pre-­implementation and post- implementation
data were collected by medical students acting
anonymously via direct observation noting the presence
of an anaesthesiologist, resident, nurse, time-­out for
procedure, checklist completed and procedure start and
sedation time representing a complete time-­out.
Results  The direct observations in the pre-­
implementation group showed a 20% (3/15) compliance
with a correct time-­out. The direct observations in the post
implementation group showed 85% (12/14) compliance.
This revealed a 65% increase in all portions of the time-­
out checklist completed. Comparative analysis confirmed
decrease in non-­compliance and deviations from protocol
as displayed by 65% increase in all portions of time-­out
checklist completed.
Conclusion  We aimed to improve safety, communication
and compliance for preoperative nerve blocks through
development and implementation of a safe preoperative
block process using a multidisciplinary model. We
conclude that creation of a safe nerve block was achieved
by integration of a preoperative nerve block process which
included increased compliance to the time-­out checklist,
verifying patients and laterality with marking of patient
prior to each procedure, identifying proper consents were
completed and ensuring each regional nerve block was
executed with a proper time-­out.
PROBLEM
Preoperative nerve blocks were being performed
without a proper time-­out, consents were some-
times missing or incomplete, laterality was
not consistently checked and there was poor
communication between nursing, surgery and
anaesthesia.1 While a pre-­procedure checklist
was informally being used, compliance was only
Arbizo JC, et al. BMJ Open Quality 2022;11:e001370. doi:10.1136/bmjoq-2021-001370
Quality improvement report
20% by initial direct clinical observations. There
were two ‘never events’ that were wrong-­sided
blocks within a 6-­year period, as well as an inci-
dent of wrong medication administration and
a recent event when sedation was given prior
to a surgical consent being completed. This
indicated that the checklist was not being used
properly and prompted the initiation of this
intervention. Failure to do a pre-­ procedure
time-­out is unsafe for our patients and resulting
complications are entirely preventable. The aim
was to ensure that all regional blocks done in
the hospital preoperative and holding area are
done with a proper time-­out (with registered
nurse (RN), anaesthesia attending and resident)
immediately prior to the regional block, before
sedation is given, as well as optimising compli-
ance with the time-­out checklist.2 Time-­out will
encompass completing all parts of the time-­out
sheet in the presence of all essential personnel.
copyright.
The hospital is a busy training institution
where the anaesthesia department regularly
performs an average of 10–12 preoperative
nerve blocks daily. Nerve blocks are used to
provide surgical anaesthesia as well as postop-
erative analgesia, but it is an invasive proce-
dure where sedation and a high volume of
local anaesthetics are often administered. The
procedure should ideally be done only after
completion of surgical consent and marking as
well as anaesthesia consent and marking along
with verification of limb laterality. However, the
busy and pressured perioperative environment
is a factor in missing checks that ensure patient
safety.
The project team consisted of a multidis-
ciplinary team of leaders in various fields
including nurses, physicians, hospital admin-
istrators, residents and medical students with
an aim to increase compliance of the time-­out
process from 20% to 80% within 5-­month inter-
vention time period.3 Medical students involved
contributed by performing direct observations
anonymously, verifying compliance with the
time-­out checklist and presence of each staff
member including nurse, attending physician
and resident. The residents role was execution
of time-­out checklist and additionally the writing
of the manuscript. Each multidisciplinary field
was involved in the Plan–Do–Study–Act (PDSA)
1
Open access
Figure 1  Anaesthesia pre-­block time-­out sheet. DOB, date
of birth; MRN, medical record number; RN, registered nurse.
cycles contributing their ideas to improving compliance and
safety.
MEASUREMENT
The Standards for Quality Improvement Reporting Excel-
lence guidelines were referred to in the preparation of this
report.4 Direct clinical observations of 29 preoperative nerve
block time-­outs were performed from December 2019 to
January 2020 at the hospital which is a large 716-­bed, level
one trauma academic hospital with 35 operating rooms
(ORs) situated on separate two floors. Observations were
not randomised and were sampled by convenience. Ortho-
paedic surgery patients in the preoperative and holding area
on the second floor was targeted specifically for observa-
tions. No specific person or staff was targeted. The observa-
tions were obtained by study staff using a standardised Excel
sheet to assess preoperative nurse, anaesthesia attending and
resident compliance with the time-­out checklist (figure 1).
The observers did not divulge their purpose when they
entered the preoperative bay for each nerve block, in order
to diminish the influence of performance observation on
nurse, anaesthesia attending or resident. The observers
recorded compliance for each element of the time-­out check-
list, presence of each member of the team including preop-
erative nurse, anaesthesia attending and resident, as well as
if a time-­out was performed or not. Elements of the time-­out
checklist that were verbalised and filled out in completion
by the anaesthesia attending performing the time-­out were
2 Arbizo JC, et al. BMJ Open Quality 2022;11:e001370. doi:10.1136/bmjoq-2021-001370
BMJ Open Qual: first published as 10.1136/bmjoq-2021-001370 on 10 January 2022. Downloaded from http://bmjopenquality.bmj.com/ on September 17, 2022 by guest. Protected by
considered compliant. Other events that occurred were also
noted during the time-­out process including the verbalised
time-­out time, the sedation and block start time.
DESIGN
The quality improvement project team consisted of three
project sponsors including the director of quality improve-
ment, the chair of anaesthesia, one perioperative nurse
manager, one lead physician anaesthesiologist, two physi-
cian anaesthesiologists, two resident physicians, a nurse
project facilitator and two medical students. Different tools
were used to evaluate and analyse the current process and
areas of insufficiency within the patient pathway. Tools
primarily used were, first, anonymous direct observations by
medical students. In addition, the direct observations were
randomised with no specific nurse, anaesthesiologist or resi-
dent being evaluated on a predetermined notion. Second,
a current state process flow diagram was created to further
identify areas of improvement. Lastly a future state process
flow diagram was developed and used for continued optimi-
sation of the process and sustainability by being on display
in the preoperative areas for education and compliance of
current and new staff.
Initially, a current state process map (figure 2) was devel-
oped to ensure the project team understood the various
members involved and steps required to have the necessary
copyright.
pieces in place to go through a time out. The preopera-
tive surgical patient journey was documented in a progres-
sive manner, from arrival in preoperative area to block
time. Areas for improvement and barriers were identified
including delays or inefficiencies in the process. A future
state process map (figure 3) was also developed for further
analysis to determine the necessary interventions to stream-
line the process.
After process mapping, we invited a broader team of OR
nurses and administrators from the hospital to further iden-
tify details in the pathway and obstacles. This process again
exposed deficiencies with the current process and appro-
priate interventions that could be applied with the broader
multidisciplinary team present. The project team met weekly
from September 2019 to February 2020 during the cycles.
Baseline data was obtained from September to November
and implementation began from end of November.
In order to produce improvement consistent with our goal
and within our reach we decided to limit our measurement
efforts to the preoperative area on a single floor focusing
on outpatients with the goal to provide the same care
throughout the entire preoperative area.
There were 15 improvement interventions that were
created in response to the areas of concern which we tested
by completing four PDSA cycles across a 20-­week period.5
Most of the practitioners were amenable to the changes
though some areas of anticipated risks for unsuccessful
compliance with the new process were the time factor for
a proper time-­out and filling out the checklist in its entirety
given the busy and pressured perioperative environment.
 Open access

BMJ Open Qual: first published as 10.1136/bmjoq-2021-001370 on 10 January 2022. Downloaded from http://bmjopenquality.bmj.com/ on September 17, 2022 by guest. Protected by
Figure 2  Flow diagram at initial education meeting reflecting current state. H&P, history and physical; IV, intravenous; OR,
operating room; RN, registered nurse.

Patients or the public were not involved in the design,
or conduct, or reporting, or dissemination plans of our
research.
STRATEGY
Our SMART aim was to ensure that all our regional blocks
were done with a proper time-­out, which encompassed
completing all parts of the time-­out sheet in the presence
of all essential personnel so that 80% are compliant at the
end of 20 weeks.6 Four PDSA cycles were performed to
accomplish this (figure 4).
Our initial intervention consisted of education of staff

copyright.
done in the hospital preoperative and holding area for 1 week with clearly defined tasks and roles for each

Figure 3  Flow diagram reflecting changes, future state. anes, anaesthesia; H&P, history and physical; IV, intravenous; IVF,
intravenous fluids; PCC, patient care coordinator; meds, medications; OR, operating room; preop, preoperative; pts, patients;
RN, registered nurse.

Arbizo JC, et al. BMJ Open Quality 2022;11:e001370. doi:10.1136/bmjoq-2021-001370 3

Open access
Figure 4  PDSA cycle process diagram. OR, operating room;
PDSA, Plan–Do–Study–Act; preop, preoperative.
team member, and implementation of our action plan
for 2 weeks (see online supplemental file 1). Attend-
ings educated attendings, nursing educated their peers
and residents educated residents. Measurements and
monitoring for compliance took place for 2 week and we
reconvened after the cycle for adjustments.7
Our action plan (see online supplemental file 1)
consisted of additional roles and tasks for each member
of the team. Including identifying elective block patients
1 day prior by the resident and marking on the electronic
operating room schedule board for clarity and so preop-
erative nurses were aware they would be required for a
time-­out. Anaesthesia residents were to also contact the
orthopaedic surgery attending by 14:00 the day prior to
confirm elective block patients and the OR board would
be updated with response. On patient arrival, preoper-
ative nurse would then assign elective block patients to
specific bays, which also made it easier to monitor post
block given that the patients receive sedation. After vitals
were, obtained, the preoperative nurse would leave on
monitors (blood pressure, pulse ox, EKG), connect IVF
(intravenous fluids), check consents, verify surgical site
marked, place nasal cannula and make sure time-­ out
checklist is at bedside. Nurse then marked ‘P’ on ORC
(operating room computer) board indicating preopera-
tive is done and OR circulator is aware. The preopera-
tive nurse number was presented on the board to contact
when ready for block. The OR circulator would then eval-
uate the patient and a handoff was performed and ‘H’
marked on ORC board indicating handoff is complete
prior to block and sedation (preoperative RN follow-­up
cases preoperative RN will call circulator to do handoff).
Anaesthesia faculty and resident team did time-­out led
by attending with preoperative RN present. The time-­out
checklist was also completed at that time to ensure
patient safety and documentation was complete. When
4 Arbizo JC, et al. BMJ Open Quality 2022;11:e001370. doi:10.1136/bmjoq-2021-001370
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block was complete anaesthesia resident updated board
and informed preoperative RN ‘block done’ and preop-
erative RN continued to monitor patient. The process is
reflected in (figure 3) ‘the future state flow chart’.
PDSA cycle 1
During the first cycle we had a week for education
where designated residents from the project team were
present in the preoperative area on the second floor
each morning to follow-­up and answer questions about
the new process (figure 3). They were also available
to remind the various residents who were rotating on
regional anaesthesia of their roles with emphasis on the
time-­out and revised time-­out checklist with all essential
members present. A PDF of the action plan with various
roles was emailed as well as posted in the preoperative
block area. We then had 2 weeks for implementation at
which point we encouraged the residents, attendings and
nursing staff to write comments on the checklists about
the process. Feedback included that the time-­out check-
lists are being filled out but without specific comments
on the process. Some attendings showed up late or were
not involving preoperative nursing in the time-­out espe-
cially for first start cases. Additional feedback noted that
putting on monitors and nasal cannula is really helpful
for the anaesthesia team. There was difficulty in locating
preoperative nurse sometimes as they were taking care of
multiple patients. During this transition an adjustment
copyright.
period occurred, as was expected, due to people being
assigned to new roles and responsibilities of specific tasks
that they previously did not conduct. Feedback received
from direct observations indicated there was a significant
improvement from baseline data that showed increased
compliance to 5 out of 6 (83.3%) witnessed time-­outs
from 3 out of 15 (20%) at baseline (figure 4).
PDSA cycle 2
A feedback comment section was added to the back of the
time-­out checklist. During this cycle there was difficulty
with regional anaesthesia residents taking the initiative
to contact the orthopaedic surgery attendings the day
before. There were delays in surgical teams marking the
surgical site in a timely manner delaying block process.
The plan was for one of the team attending anaesthesiol-
ogists to touch base with orthopaedic attendings to make
sure they were on board and understood the process as
well as to emphasise the need for early surgical site mark-
ings for this process to work smoothly. The project faculty
was also sending out emails to anaesthesia attending’s to
emphasise the need to arrive on time, lead the time-­outs
and include nursing staff. Direct observations indicated
there continued to be significant improvement from
baseline data that showed increased compliance with
seven out of eight witnessed time-­outs (87.5%) (figure 4).
PDSA cycle 3
We hypothesised that in order to further build and
strengthen our new process, a visual intervention would be

Figure 5  Results bar graph. preop, preoperative.
beneficial for staff. Therefore, a time-­out video on ‘What
not to do’ and ‘What to do’ production was initiated. We
went over producing the time-­out video including writing
scripts, which was delegated to the medical students and
residents. Hospital staff were chosen to be actors for the
video. Direct observations continued to show improved
compliance with occasional logistic issues as noted
(figure 4).
PDSA cycle 4
For our final cycle, we reviewed the handoff process for
the OR circulators with the OR nurse managers. Hospital
policy was changed which directly impacted the preop-
erative process that the OR circulators will still interview
the patient and verify consents, but they will not have
the pressure of doing this prior to sedation or the block
being done. This would increase efficiency for the blocks.
We found that compliance remained high with the
time-­out process in the final cycle with the above changes
(figure 4).
RESULTS
Our main outcome measure was compliance with the
time-­out process including completion of the checklist
with all essential team members present and measured
via direct observations of trained project team members.8
The compliance improved quickly from baseline and
remained high, from 20% to 85%9 (figure 5).
A period for assessment of baseline data via direct
observations showed preoperative nurse was present 20%
(3/15) for time-­out, anaesthesia attending and resident
present 100%, all components of time-­out checklist was
completed 20% (3/15), time-­out for procedure completed
in 66% (10/15). Weekly direct measurements were
obtained post implementation and showed the preop-
erative nurse was present 80% for procedure time-­out,
anaesthesia attending and resident present 100%, all
portions of revised time-­out checklist was completed 85%
(12/14), time-­ out procedure was performed in 100%
(14/14) of cases prior to sedation time and block start
time. In two cases the nurse was present for identifica-
tion of patient and then left and never came back. There
was 60% improvement in compliance with nursing staff
presence and 44% improvement in compliance with
Arbizo JC, et al. BMJ Open Quality 2022;11:e001370. doi:10.1136/bmjoq-2021-001370
Open access
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time-­out for the procedure. There was 65% increase in
all portions of time-­out checklist completed. Comparative
analysis demonstrated an increase in compliance with the
implementation of the safe preoperative block process
(figure 5).
Lessons and limitations
The project aim was to ensure that all our regional blocks
done at the hospital preoperative and holding area
were done with a proper time-­ out, which encompassed
completing all parts of the time-­out sheet in the presence
of all essential personnel. To achieve this, we made signifi-
cant modifications to the existing preoperative nerve block
process. Building on existing ideas, we also wanted a process
that improved safety and communication between anaes-
thesia, nursing and surgery teams.10 It can be stated that the
compliance-­promoting measures made an important contri-
bution to this result.11 A key lesson learnt during the process
was the importance of PDSA cycles, which helped to ensure
the integrity of the multidisciplinary model and that each
step was optimised prior to implementation of interventions.
As strong multidisciplinary communication rests at
the core of the process, we made sure that anaesthesiolo-
gists, residents, nurses and administrators were involved
throughout the process including discussions, planning,
collecting written feedback and attending meetings.10 Their
input during the planning was essential to increase their
support for a viable new process. Notwithstanding, we did
copyright.
identify certain implementation problems, which we attri-
bute to the fact that it was not possible to meet with the
entire nursing staff, surgery faculty, anaesthesia faculty and
residents. Having included a surgery resident or faculty
surgeon initially in the project team may have improved this
issue of the process.
Project implementation exposed the obstacles of staff
acceptance to a new process. Despite prompt positive results
it can take time to establish new sustainable routines espe-
cially in higher pressured environments where efficiency
is important such as the perioperative areas. Qualitative
feedback from staff post implementation has been vital in
refining the process and we believe is essential for long-­term
success.8 The qualitative feedback does suggest the need for
continued education as staff turnover ensues and new resi-
dents arrive. A time-­out video of what to do and what not to
do is in production in order to encourage long-­term sustain-
ability of the process. The hospital’s creative media service
has reviewed the script for the block time-­out video with
plans for filming to commence soon. Additional anaesthesia
and orthopaedic surgery attendings agreed to participate in
the video improving our multidisciplinary model. We should
have a date for filming soon.
Finally, we primarily focused on nerve blocks located on
the second floor preoperative area at the hospital and did
not obtain data in other areas of the hospital including the
third floor preoperative area or post-­anaesthesia care units.
Therefore, we have drawn our conclusions based on obser-
vations restricted to one area, which is a limitation. We have
not performed any statistical tests to prove that these results
5
Open access
are not a product of chance. In order to overcome this,
ideally more data would need to be collected over a longer
time period and statistical tests would need to be performed.
There is also the possibility of confounding bias, for example,
due to the change in anaesthesia residents on regional every
4 weeks, and the hiring of new anaesthesiologists throughout
the year both of which may have positively impacted the
time-­out process, independent of our intervention.
Another limitation is how we collected our data. Ideally,
this would be an automated, bias-­free, systematic process.
However, the project relied on medical students to manually
collect and observe each procedure so there is observer bias.
There were also limitations to the number of procedures
they were able to see because of prior engagements in their
own schedule.
Although the new preoperative nerve block process has
substantially helped to improve compliance with the time-­out
checklist and communication between the various teams,
continued monitoring for sustained commitment to the
process and compliance is necessary. For this to be improved
further, a future project should look into applying the safe
preoperative block process to all areas of the hospital where
nerve blocks are performed. This is an opportunity we hope
to pursue in the near future.
CONCLUSION
Non-­ compliance with the preoperative nerve block
time-­out and checklist can lead to adverse events. This
study’s goal was to ensure that all regional nerve blocks
in the preoperative/holding area at the hospital were
executed with a proper time-­out with a nurse, anaes-
thesia attending and resident immediately prior to the
regional block and before sedation. The implementa-
tion of a safe preoperative block process including a
revised time-­out checklist was used to increase compli-
ance with the time-­out procedure and facilitate good
communication between the multidisciplinary teams.
Results displayed significant improvement with compli-
ance from baseline data and sustainable over an
extended period of months.
Evidence has shown that procedural time-­ outs and
checklists have been proven to be effective means of
improving teamwork and preventing wrong-­sided proce-
dures. Increasing evidence also shows that these effects
translate into safer patient outcomes. Our project has
demonstrated that simple interventions can improve
compliance and communication among nursing, anaes-
thesia and surgery teams. There were no wrong-­site or
wrong-­person blocks reported at our hospital during the
study period.
Although the new preoperative nerve block process
has substantially helped to improve compliance with
the time-­out checklist and communication between the
various teams in a limited area, continued monitoring
for sustained commitment to the process and applica-
tion on a larger scale is necessary. For this to be improved
further, a future project should look into applying the
6 Arbizo JC, et al. BMJ Open Quality 2022;11:e001370. doi:10.1136/bmjoq-2021-001370
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safe preoperative block process to all areas of the hospital
where nerve blocks are performed. This is an opportunity
we hope to pursue in the near future.
Contributors  Author JCA and coauthors VL, FR, TA and KD conceived initial idea,
processed the experimental data, performed the direct observations and analysis,
drafted the manuscript and designed the figures. All authors discussed the results
and commented on the manuscript, contributed to the design and implementation
of the quality improvement report and to the writing of the manuscript. Author and
coauthors acknowledge project sponsors: Emily Volk, MD; Lisa Devane, MSN; and
Ms Polly Smith, RN; and quality improvement project members: Matt McClure, MD;
Wendy Kang, MD; Naveen Mehra, MD; and Beena Chorath, RN, who were involved
in planning meetings, implementing and supervising the work. Author JCA is
responsible for overall content acting as the guarantor.
Funding  The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests  None declared.
Patient consent for publication  Not required.
Ethics approval  This study does not involve human participants.
Provenance and peer review  Not commissioned; externally peer reviewed.
Data availability statement  All data relevant to the study are included in the
article or uploaded as supplementary information.
Supplemental material  This content has been supplied by the author(s). It has
not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been
peer-­reviewed. Any opinions or recommendations discussed are solely those
of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and
responsibility arising from any reliance placed on the content. Where the content
includes any translated material, BMJ does not warrant the accuracy and reliability
of the translations (including but not limited to local regulations, clinical guidelines,
terminology, drug names and drug dosages), and is not responsible for any error
and/or omissions arising from translation and adaptation or otherwise.
copyright.
Open access  This is an open access article distributed in accordance with the
Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,
and license their derivative works on different terms, provided the original work is
properly cited, appropriate credit is given, any changes made indicated, and the use
is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.
ORCID iD
Joseph Christopher Arbizo http://orcid.org/0000-0001-9065-6094
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